Does insurance cover the cost of a high-risk pregnancy?

Does insurance cover the cost of a high-risk pregnancy?

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Most women with a high-risk pregnancy end up needing a lot of extra tests and treatments that add to the overall cost of having a baby. Since different plans offer different coverage, understanding what to expect can help you make sense of the bills and keep costs under control. Here's what you need to know.

What is a high-risk pregnancy?

A high-risk pregnancy means you or your baby is at risk for serious health problems or complications during pregnancy or after the baby is delivered. Your pregnancy might be considered high-risk if:

  • You have a condition like hypertension, preeclampsia, diabetes, anemia, or HIV.
  • You smoke, abuse alcohol, or use recreational drugs.
  • You're carrying twins or more.
  • You're younger than 16 or older than 34.

If I'm high-risk and uninsured, can I get health insurance?

Yes. Under the Affordable Care Act (ACA) you can't be refused coverage for being high-risk or having any other pre-existing condition. And because pregnancy is a change in status, you can enroll in a health plan at any time, even outside the normal enrollment period. Learn how to find a plan.

Will my plan cover the cost of a high-risk pregnancy?

Different plans offer different coverage for certain tests and procedures. Call your insurance company or look online to find out what your plan covers.

The extra costs are likely to start accumulating as soon as you know you have a high-risk pregnancy, and most plans have an out-of-pocket maximum. Check yours to find out the most you'll have to pay as long as you stay in network.

"In network" means your healthcare provider has a contract with your insurance company. Staying in network usually saves you money.

In addition to keeping your costs in check, knowing as much as you can ahead of time makes a big difference in other unexpected ways. Jenny Smith of Austin, Texas, had insurance through her employer in 2015 when she learned she had a blood-clotting disorder early in her pregnancy. Shortly afterward, she discovered that the $6,000 deductible was the most she would have to pay.

This was a great relief when Smith underwent $1,800 worth of blood work at 8 weeks pregnant and found out she had to inject herself with a costly blood thinner every day for the duration of her pregnancy and for six weeks after delivery.

Over the course of Smith's pregnancy, she was seen at the hospital 23 times, told twice she may be having a miscarriage, and warned she would need a c-section. But she beat the odds and delivered a healthy baby boy without surgery.

Smith says that the charges for her pregnancy came to about $45,000, so even though the $6,000 deductible was expensive, it was a small fraction of the cost. "I had peace of mind, absolutely. I don't know how people sleep at night not knowing if they're covered and what it's going to cost."

How to control the cost of a high-risk pregnancy

Speak the language of insurance benefits. Knowing how your plan works, and how to use these documents, can help you decide which insurer to pick and stay on top of expenses once you're enrolled:

  • Summary of Benefits and Coverage (SBC) – This is a standard form in plain language that all insurers have to provide. With an SBC, you can compare the benefits of different plans while you're insurance shopping. It includes examples of coverage for common medical situations.
  • Evidence of Coverage (EOC) – You'll receive this document when you first sign up for insurance. It describes in detail the benefits covered by your health plan and documents exactly what the plan covers, including how much you should expect to pay.
  • Explanation of Benefits (EOB) – An EOB is sent to you for every claim submitted to your insurance company. It contains the name of your provider, date of service, actual billed amount, discount amount (for in-network providers), what portion went to your deductible, co-pay or coinsurance amount (if any), and how close you are to your out-of-pocket maximum. The footnotes are important because they explain what's happening within the claim.

Track your expenses. Independent insurance agent Carol Eejima advises to start tracking your expenses as soon as you go to your first prenatal appointment. Eejima says being organized minimizes unexpected financial surprises from cropping up.

Keeping everything organized enables you to spot discrepancies between the billing statements from the doctor or hospital and the statements you receive from your insurance carrier.

Also, get as much as you can in writing from your insurer concerning the coverage of a treatment or procedure. Keep a log of each call that includes a reference number, the name of the person you spoke with, and the date and time of the call.

Keep paper statements in a binder or electronic copies in a folder on your computer. Here's what to include:

  • Doctor bills
  • All correspondence from the insurance company
  • Contact numbers for your doctors' billing offices and for the insurance company
  • Documents from your insurer (EOBs)

Know what you're paying for. Insurance statements make most people's eyes glaze over, but it's important to be familiar with the terms on your EOB so you know what's covered.

For example, if you have outstanding bills you think the insurer should cover, knowing these terms helps you make a stronger case when you call to ask for an explanation or protest an uncovered bill. Here are the definitions of key terms:

  • Premium – The amount you pay your insurance company each month to be a member of the plan.
  • Deductible – How much you have to spend for covered health services before your insurance company pays (unless you're having free preventive services in network or your plan has specific co-pays for certain services). Note that the deductible may be different if you use out-of-network providers.
  • Co-pay – The portion you pay for a doctor's visit, treatment, or test.
  • Coinsurance – Your share of the cost of a covered health care service prior to or after meeting the deductible, depending on your plan. This information will be a percentage (10 percent, 20 percent, etc.).
  • Out-of-pocket maximum – This is the most you have to pay and usually includes co-pays, coinsurance, and deductible. After you reach this amount, the insurance company pays 100 percent for eligible services. (Note that the out-of-pocket maximum is usually different for out-of-network providers.)

Questions to ask your insurer

Whether you're choosing a new plan or need information about your current one, here are specific questions to ask about your high-risk pregnancy coverage.

  • Is my ob-gyn, maternal-fetal medicine specialist (perinatologist), or other caregiver covered under my plan? You don't want to get the shock midway through your pregnancy that your healthcare provider is out of network and you have to pay more for services. Make sure your crucial providers – including your internist and your baby's doctors – are in the plan's network from the get-go. If you need to see an out-of-network specialist, find out if your plan will still cover part of the cost.
  • Do I need preauthorization for prescription medicines or specific tests or treatments? Check to see if your medication requires preauthorization before you pay for it, and be prepared to ask your doctor for help with an appeal if your claim is rejected. "We're finding that many companies don't cover certain drugs, particularly if they're experimental or expensive," Eejima says. As for specific tests and treatments, make sure your provider's office and hospital communicate with your insurer about anything that might need preauthorization.
  • What portion of my pregnancy and birth expenses will be covered? This should be spelled out in the EOC, where you see your costs listed, including the hospital fees for the birth. However, some situations may be outside the scope of regular pregnancy coverage, such as being seen in the emergency department.
  • Can I authorize a family member to discuss my claims with the insurer? Insurers may not talk to your spouse, partner, or other family member unless you give permission in advance. Call your plan to find out what you need to do to make this happen. If you're hospitalized during your pregnancy, the last thing you want to worry about is dealing with your insurer about the cost of your hospital stay.
  • If I get pregnant in one year and deliver in the following year, does one deductible cover the entire pregnancy? In most cases, the deductible does not carry over to the next year. Instead, the amount you must pay for the deductible begins from zero in the new calendar year.
  • Are midwives and doulas covered? Some insurers cover services from midwives, but doulas (birth coaches) are usually not covered. You might be able to use a midwife or doula to complement the delivery team in a hospital, but don't assume it will be covered by your plan. Check with your insurance company or be prepared to pay out of pocket.
  • What if my baby requires expensive treatments? Your baby's care is covered automatically at birth, but there are exceptions for some services. You also must remember to add your newborn to your insurance policy within 30 days from the date of birth. In 2010, the average unsubsidized (non-Medicaid) insurance payments made for infant care in a neonatal intensive care unit were about $30,000 for a baby born vaginally and $45,000 for a baby born by c-section, according to the National Partnership for Women & Families. Parents' out-of-pocket costs were about $1,200 and $1,300 respectively – as long as their baby was covered.

Where to go next

Watch the video: Giving birth costs a lot. Hospitals wont tell you how much. (August 2022).

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